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May 19, 2009
Dear Mr. President

First of all, allow me on behalf of the hospitalist community to congratulate you on your first 100 days as Hospitalist-in Chief. In these first days of your administration, you’ve succeeded in implementing several key hospitalist-specific core measures, such as decreasing length of stay for our soldiers in Iraq and for prisoners in Guantanamo, establishing strict pay-for-performance standards for bankers and car company executives, and instituting family-centered care at the State Department. Suffice it to say, you have made your hospitalist colleagues proud!

As you continue to multitask like any good hospitalist would, with the help of your Blackberry and non-physician providers, let me offer some tips to help you tackle the biggest hurdle in your short administration. No, it’s not the nomination of the next Supreme Court justice—although I have heard that being a judge is not a requirement. (Respectfully, if you nominate me, it’d be a historic nomination: the first … physician in the Supreme Court.)

My advice is regarding the health care system. Here are some suggestions I’ve gathered from our esteemed hospitalist colleagues whose names I won’t mention, in case they don’t remember giving me their advice:

First: Eliminate state medical boards and hospital credentialing committees. Why do I have to pay thousands of dollars to one state to allow me to practice there when I’ve paid another state to allow me to do the same?

It’s not as if the practice of medicine varies from state to state, right? Otherwise, they’d make you take a test in each state. In Alaska, for example, you'd have to display your knowledge of moose hunting injuries; in Texas, you'd be tested for oil-spill inhalational injuries; in California, you'd have to show what you know about burn management. And while we’re at it, why does each hospital have its own credentialing process? It’s not like the Foley catheters or central-line kits differ from institution to institution.

Projected cost savings: $500 billion.

Second: Eliminate subspecialists in favor of adding more hospitalists. We’re already seeing “our kind” take over other medical and surgical services. What do you think “co-management” means?

We already have hospitalists covering ICUs, emergency rooms and deliveries. Why not have neurosurgical hospitalists or psychiatric hospitalists? (Actually, I understand we already do.)

This initiative will cut waiting times for specialty care and allow every hospital to have a full cadre of subspecialists in-house 24/7, reducing unnecessary transfers. Former subspecialists can be shunted to underserved areas to serve as general practitioners.

Projected saving: $300 billion, plus the eternal gratitude of psychiatrists.

Third: Institute lifestyle-related pay for access. In all the talk about how to fix health care, all I hear is what doctors, hospitals and insurance companies need to do. But I haven’t heard a single thing about patients' responsibility.

Because they have rights, they should also be held accountable for their lifestyle. So if you're overweight, and need to be evaluated for acute chest pain, the emergency room physician will deny care unless the patient signs a pledge to lose weight.

Smokers would have to pay the same amount of money that they spend on cigarettes for chest X-rays. And overweight kids would be sent to weight-loss boot camps in the African jungle, where they’ll lose weight, achieve a high level of cultural education and return with a natural immunity to malaria, thereby decreasing the costs of vaccination research. Now, that’s change you can believe in!

Projected savings: $1 trillion, which will serve to stimulate the legal system and the Supreme Court.

And my final proposal: Eliminate EMTALA. This outdated piece of legislation was crafted in the 80s to avoid patient dumping. In today's brave new monetary century, we should consider these patients “toxic assets” and create a successful financial system to deal with them.

Let’s take a page from the environmental industry’s playbook and form a cap-and-trade system similar to emission trading exchanges. Each hospital will get credits for how many unassigned patients they should treat. If they end up with more, they can trade those patients to another hospital, selling hospitals the rights to those patients. If a hospital needs more patients, they can buy them from somewhere else.

No dumping would happen because, seriously, what hospital can survive without patients? If no hospital wants them, we can sell those credits overseas to China. After all, they buy all our other debt.

There it is, Mr. President, from one hospitalist to another. I hope you give these proposals some serious consideration and rest assured that we can take all the committee meetings you need. After all, part of hospitalist training is the secret art of ninjutsu: appearing to have one’s eyes open during endless meetings, while the mind is in a permanent, absent bliss.

By the way, I hear you still don’t have a surgeon general. How about a hospitalist?
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About Ruben J. Nazario, MD
Ruben J. Nazario, MD, is now medical director at Inovalon, a health care data analytics company, and is medical editor for Elsevier's First Consult. A pediatric hospitalist, Dr. Nazario is a veteran of both community and academic pediatric hospitalist programs. All material represents his own views and does not reflect the views of his employer.
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